on Troubleshooting During Laparoscopic Colorectal Surgery

Fig. 10.1

Palmer’s point : two fingerbreadths below the left costal margin in the midaxillary line

Regardless of the technique chosen for entry, the first step following port placement should be a visual inspection of the abdomen for injury. This can include the obvious, such as bleeding or enteric contents or the subtle, such as a retroperitoneal hematoma or hollow viscus injury. Any failed entry site should be inspected to assess for any associated injury. Hollow viscus injury may be repaired with oversewing as appropriate. Small bleeding can be controlled with an energy device. Larger bleeding may require vascular repair, and early consultation from a vascular surgeon is recommended. Bladder injury may require closure in layers and use of a Foley catheter for decompression for an extended period postoperatively. Urology consultation is recommended.

Laparoscopic entry can cause injury to vessels of the abdominal wall. Access sites are carefully chosen to avoid major vessels. Abdominal wall bleeding may not be immediately apparent until after the port is removed because the port may tamponade muscular or subcutaneous bleeding. In addition to visually inspecting the access site upon its creation, all laparoscopic port sites should also be observed during and following port removal. Bleeding points can usually be identified and managed with electrocautery or sutures as necessary. If bleeding persists, a Foley catheter may be inserted, inflated, and pulled back against the abdominal wall to tamponade the site. U-stitches can then be placed into the abdominal wall under direct laparoscopic visualization using a suture passer with absorbable braided suture. With uncontrolled bleeding, the skin incision may need to be enlarged to control the bleeding. Both proximal and distal to the injured portion of the vessel must be sutured.

Equipment Issues

Once pneumoperitoneum has been established and ports are placed, there are a few potential issues that can take place with any laparoscopy equipment. Major issues include low pressure, high pressure, problems with lighting, and problems with the picture. Troubleshooting tips are summarized in Table 10.1. A couple of issues will be highlighted here in the text.

Table 10.1

Troubleshooting guide

Problem	Cause	Solution
Poor insufflation/loss of pneumoperitoneum	CO₂ tank empty	Change tank
	Accessory port stopcock(s) not properly adjusted	Inspect all accessory ports. Open or close stopcock(s) as needed
	Leak in sealing cap or stopcock	Change cap or cannula
	Excessive suctioning	Allow time to reinsufflate
	Loose connection of insufflator tubing at source or at port	Tighten connections
	Hasson stay sutures loose	Replace or secure sutures
	Tubing disconnection from insufflator	Connect tubing
	Flow rate set too low	Adjust flow rate
Excessive pressure required for insufflation (initial or subsequent)	Veress needle or cannula tip not in free peritoneal cavity	Reinsert needle or cannula
	Occlusion of tubing (kinking, table joints, etc.)	Inspect full length of tubing. Replace with proper size as necessary
	Port stopcock turned off	Fully open stopcock
	Patient is “light”	Give more muscle relaxant
	Cannula tip not in peritoneal space	Advance cannula under visual control
Inadequate lighting (partial/complete loss)	Loose connection at source or scope	Adjust connector
	Light is on “manual-minimum”	Go to “automatic”
	Bulb is burned out	Replace bulb
	Fiber optics are damaged	Replace light cable
	Automatic iris adjusting to bright reflection from instrument	Reposition instruments or switch to “manual”
	Monitor brightness turned down	Readjust setting
	Room brightness floods monitors	Dim room lights
Lighting too bright	Light is on “manual-maximum”	Go to “automatic”
	“Boost” on light source is activated	Deactivate “boost”
	Monitor brightness turned up	Readjust setting
No picture on monitor(s)	Camera control or other components (printer, light source, monitor) not “on”	Make sure all power sources are plugged in and turned on
	Cable connector between camera control unit and/or monitors not attached properly	Cable should run from “video out” on camera control unit to “video in” on primary monitor. Use compatible cables for camera unit and light source
	Cable between monitors not connected	Cable should run from “video out” on primary monitor to “video in” on secondary monitor
	Input select button on monitor doesn’t match “video in” choice	Assure matching selections
Poor picture quality
Fogging/haze	Condensation on lens from cold scope entering warm abdomen	Gently wipe lens on viscera; use antifog solution or warm water
Fogging/haze	Condensation on scope eyepiece, camera lens, coupler lens	Detach camera from scope (or camera from coupler), and inspect and clean lens as needed
Flickering electrical interference	Moisture in camera cable connecting plug	Use suction or compressed air to dry out moisture (don’t use cotton tip applicators on multipronged plug)
	Poor cable shielding	Move electrosurgical unit to different circuit or away from video equipment
	Insecure connection of video cable between monitors	Reattach video cable at each monitor
Blurring, distortion	Incorrect focus	Adjust camera focus ring
	Cracked lens, internal moisture	Inspect scope/camera, and replace if needed
	Too grainy	Adjust enhancement and/or grain settings for units with this option

Adapted with the permission of the Society of American Gastrointestinal and Endoscopic Surgeons. From: SAGES Laparoscopy Troubleshooting Guide https://www.sages.org/wp-content/uploads/troubleshootingchart.pd

Low pressure can be due to several etiologies. First, check that the CO₂ tank is full and that all lines and stopcocks are open or closed as appropriate. Next, check to make sure the ports are not leaking. If a port leaks during surgery, it can be due to the fascial defect being too large or excessive port angulation . Leaks can also be decreased with additional sutures or the placement of a towel clamp to cinch the tissue closed around the trocar. Petrolatum-coated gauze may also be used to reduce the flow of any air leak. If available, balloon-tipped trocars can be used to eliminate a leak.

High pressure can result from several factors. Begin by inspecting insufflation tubing and stopcocks and that the insufflator is set on the correct pressure. High pressure can also be a result of the patient being inadequately paralyzed. Discussion with anesthesia regarding redosing of muscle relaxant is appropriate.

Investigation of poor lighting begins with tracing the light cord back to the light source and ensuring an appropriate connection. The light source itself should be checked and make sure the bulb is lit. The laparoscope should be cleaned to remove any material that may block the light. Finally, consider replacing the light cord as the fiber-optic cables can crack over time.

Troubleshooting an inadequate picture on the monitor involves a number of steps. As with the above issues, first start by tracing the camera cord and ensuring all cables are plugged in to the appropriate sites. The camera connection with the laparoscope should be examined and made sure it is tight. The laparoscope should be cleaned of any debris. If these measures fail, first replace the camera and then the laparoscopic tower.

Should any of these measures fail to fix the problem, the local representative of the laparoscopic equipment should be contacted for assistance.

Physiologic Issues

Laparoscopic surgery utilizes gas (usually CO₂) to insufflate the abdominal cavity to supernormal intra-abdominal pressures. The elevated intra-abdominal pressure, along with patient positioning and carbon dioxide absorption, can cause changes in physiology, especially in the respiratory and cardiovascular system. In most instances, the body can adapt to these changes without significant issues. But in certain scenarios, physiologic changes may become life threatening.

Nodal rhythm, sinus bradycardia, and asystole can all result from stretching of the peritoneum. Such effects usually take place at the beginning of insufflation because of the rapid stretching of the peritoneum. Should any arrhythmias be noted, immediate communication between the anesthesia and surgery team should take place. The abdomen should be desufflated as quickly as possible, and pharmacologic correction of the arrhythmia should be initiated.

The most frequently used gas for insufflation is CO₂. It is colorless, nontoxic, and nonflammable and has the greatest margin of safety in the event of a venous embolus as it is highly soluble. As it is readily absorbed from the peritoneum, it can cause an increase in PaCO₂. This has direct, as well as indirect (by raising catecholamine levels), effects on the cardiovascular system. Tachycardia, increased cardiac contractility, and reduction in diastolic filling can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischemia. Constant monitoring of the ECG rhythm strip for signs of ischemia is essential. Any evidence of ischemia should be communicated, and the abdomen should be desufflated promptly.

If CO₂ is insufflated directly into a blood vessel or if gas is drawn into an open vessel by the Venturi effect, venous gas embolism can occur. This is a rare but potentially fatal occurrence. The physiologic effects of carbon dioxide are less than that with air because of the greater blood solubility. The clinical signs of a venous gas embolus begin with an abrupt decrease in the end-tidal CO₂ levels and are accompanied by hypotension and desaturation. A “mill wheel” murmur may be auscultated on physical exam. A transesophageal echocardiogram is usually required to evaluate the embolism. Treatment includes rapid deflation of the abdomen placement of the patient in the left lateral Trendelenburg position and resuscitation. If severe, the gas can be aspirated with a central line.

Optimizing Laparoscopic Exposure

OR Table Positioning

Obtaining proper exposure is one of the key elements to successful completion of any surgical procedure. As opposed to open surgery, where retractors can be easily placed, laparoscopic surgery presents more of a challenge. Gravity remains the greatest retractor available to the laparoscopic surgeon, and its use requires safe manipulation of the operating table to achieve exposure of the intended operative field. Mobilization of the splenic flexure can be aided by placing the patient in reverse Trendelenburg; rectal surgery is aided by placing the patient in Trendelenburg. Additional exposure can be provided by rotating the operative bed to the right or the left. Beyond gravity, additional ports and intraperitoneal retractors can be helpful as well. Position changes and additional retractors all introduce new complexities to the operation and provide opportunities for complications. Appropriate foreknowledge of these pitfalls can help to avoid them.

Trendelenburg exposure, or placement of the patient in the supine position, with the feet elevated above the head with the bed placed at an incline relative to the floor, is essential in pelvic laparoscopy (Fig. 10.2a, b). This position allows the intestine and peritoneal organs to fall upward toward the chest, providing a clear view of the pelvis. This introduces many challenges, both operative and anesthetic. From a very basic point of view, the patient must be securely placed on the operating table. Patient movement on the operative table can lead to surgical injuries, positioning injuries including neuropathies, and, in the extreme case, trauma from an unexpected fall. Physiologic risks of the Trendelenburg position include lower extremity compartment syndromes, increase in intraocular pressure, decrease in cerebral oxygenation, and a reduction in pulmonary compliance.